COVID-19 Vaccine Appointment & Consent

This appointment is for the COVID-19 vaccine.

Please note the following:

The COVID-19 vaccine is approved for everyone age 6 months and up.

The CDC has approved vaccines for children 6 months and up. In California, pharmacists are only allowed to independently provide vaccines to individuals age 3 and over. We will not be able to administer vaccines to anyone under 3.

The Infant/Toddler Dose is only available as the New Bivalent Booster Dose regardless of receiving any previous dose(s) in either Moderna or Pfizer. Moderna is approved for ages 6 months to 5 years. Pfizer is approved for ages 6 months to 4 years.

Pfizer (age 5 to 11 or 12+) or Moderna (age 6 to 11 or 12+) are only available as the New Bivalent Booster Dose regardless of receiving any previous dose(s). A 2nd Bivalent Booster Dose is available after 4 months following the first Bivalent Booster Dose for individuals age 65 and over. A 2nd Bivalent Booster Dose is available 2 months following the first Bivalent Booster Dose for Immunocompromised individuals 6 months of age and over.

Janssen (J&J) is currently not available at this pharmacy.

Novavax is currently not available at this pharmacy.

The CDC has vaccine recommendations available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html. Vaccine information and disclosures are also available at www.hendrickspharmacy.com/covid19.

Which COVID-19 brand would you like to receive at this appointment?*

Vaccine Recipient Date of Birth*

Age

A parent or guardian must be present during the vaccine appointment for any patient under age 18.

	Check box
Check this box to indicate that a parent or guardian will be present during the entire vaccine appointment and will sign the consent form.

Any COVID-19 Previous Dose?*

	Yes	No
Have you ever received a dose of ANY COVID-19 Vaccine?

Which dose do you need?

The 3rd Dose (also known as an Additional Dose) is currently only available for people who have a moderately to severely weakened immune system and have received the first 2 doses (or single dose for Janssen) at least 28 days prior.

	Check box
Check this box to indicate that you meet the criteria outlined by the CDC to be eligible to receive the Additional Dose. You will be required to sign an attestation upon arrival before receiving the Additional Dose.

The First Booster Dose has been approved for individuals ages 5 to 11 after 5 months of completing the primary series of the Pfizer vaccine. You must bring your vaccine card or valid proof of previous doses to your appointment.

	Check box
Check this box to indicate that you are age 5 to 11 and have completed the primary series of Pfizer at least 5 months prior and you will bring VALID proof of previous vaccine doses to the appointment.

The Bivalent Booster Dose has been approved for individuals age 6 months and over. You must bring your vaccine card or valid proof of previous dose(s) to your appointment.

	Check box
Check this box to indicate that you are 6 months or over and you will bring VALID proof of previous dose(s) to the appointment.

Please indicate how you qualify for the Booster Dose (i.e. Age, Work, or Health Condition).

COVID-19 Vaccine Manufacturer for the previous dose received

Date of last dose of COVID-19 Vaccine that you received

Date

Sorry, you must select the same brand for your second dose as the first dose.

The CDC has approved mixing brands for Booster Doses, only after completing the primary series.

Please contact the pharmacy for additional assistance.

Sorry, you must be at least 12 years of age to receive the Pfizer (Age 12+) or the Novavax Vaccine.

You must be at least 5 years of age and less than 12 to receive the Pfizer (Age 5-11) Vaccine.

Please change your selection or correct your birth date.

Sorry, the First Booster Dose has only been approved for the Pfizer Vaccine for ages 5 to 11. Please check the Birth Date entered or select a different dose.

Weakened Immune System?*

	Yes	No
Do you have a moderately to severely weakened immune system caused by something such as an HIV infection or active cancer treatment or do you take immunosuppressive drugs or therapies?

Select an appointment time (Your selection for an appointment is not set until you complete and submit the entire consent form below.)*

Vaccine Recipient Name*

First NameMiddle NameLast Name

Gender at birth*

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code

Email (to receive notification of appointment and informational documents)

example@example.com

AGE

Race*

Required by California Department of Public Health

Ethnicity*

Required by California Department of Public Health

Vaccine Recipient Phone Number*

A Cell Phone is preferred to obtain access to the California Digital Record

Mother's First Name*

Required for proper vaccine documentation

Primary Care Provider Name

If you would like to have a copy of this record sent to your Primary Care Provider, please provide name here.

Emergency Contact Name*

Relationship to Emergency Contact*

Phone Number of Emergency Contact*

Sorry, the Bivalent Booster Dose has only been approved for ages 5 and up for Pfizer or ages 6 and up for Moderna.

Please check the Birth Date entered or select a different dose.

Novavax does not have a Bivalent Booster.

Please select a different brand or a different dose.

Sorry, the Additional Dose (immunocompromised person) is for individuals who are moderately to severly immunocompromised.

Visit the CDC website for details regarding who is considered moderately to severely immunocompromised.

Please review your selections and make the necessary correction(s).

If you have further questions, please contact the pharmacy.

Previous COVID-19 vaccine dose

	Yes	No
Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?

COVID-19 Vaccine Screening Questions (If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional information may be necessary before vaccination.)*

	Yes	No
1. Have you ever had an allergic reaction to any component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures, or Polysorbate?
2. Have you received hematopoietic cell transplant (HCT) or CAR-T-cell therapies since receiving the COVID-19 Vaccine?
3. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
4. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
5. Have you ever had COVID-19 AND was treated with monoclonal antibodies or convalescent serum or was diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A)? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
6. Do you have a history of myocarditis or pericarditis?
7. Do you have a history of thrombosis with thrombocytopenia (TTS) following an adenovirus-vectored vaccine (e.g. Johnson & Johnson, AstraZeneca, or Sputnik COVID-19 vaccines)?
8. Do you have a bleeding disorder or a history of heparin-induced thrombocytopenia (HIT) or are you taking a blood thinner?
9. Are you pregnant or breastfeeding?
10. Have you received dermal fillers?
11. Have you had Guillain-Barre Syndrome, a condition that causes paralysis?

Consent (check each box below after reading and prior to signing the form)*

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this Consent Form (also available online at http://www.hendrickspharmacy.com/covid19). I have had a chance to ask questions that were answered to my satisfaction. I am eligible to receive the vaccine at this time according to the current guidelines and I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I acknowledge that my immunization information from this visit will be sent to the California Immunization Registry and may be shared with other providers unless I choose to opt out.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Hendricks Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s).
I have read and reviewed the Notice of Privacy Practices available at www.HendricksPharmacy.com.
I understand that I will be receiving the vaccination at no cost to me.

Insurance (The vaccine is available to anyone no matter if insured or uninsured.)*

	Yes	No
Do you have health or medical insurance (examples include Medicare, Medi-Cal, or private health policies)?

Type of insurance

Please select the type of prescription insurance that you have.

Insurance ID#

Please enter the ID# from your insurance card (Medicare, Medi-Cal, Kaiser, or Private/Other).

The vaccine is available to anyone no matter if insured or uninsured. Since you indicated you have insurance, please read and check this box.

	Check box
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.

The vaccine is available to anyone no matter if insured or uninsured. Since you indicated you do not have insurance, please read and check this box.

	Check box
If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance

ID #

Please enter your State ID/Driver's License #

Full Name

Date/Time

DoseDate

Date

Hour MinutesAM/PM Option

NextDoseText

Next Dose Due

Date

Time

Hour Minutes

AM/PM Option

CurrentDate

Date

COVID-19 Vaccine Appointment and Consent Form